Which nursing diagnosis may be identified for a patient with hyperthyroidism?

Classification Section

Nursing Type Primary: acute care

Nursing Type Secondary: not applicable

System Primary: endocrinologic

System Secondary: not applicable

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Ask patients if they use tobacco products or have high levels of stress in their life. Often, patient report intolerance to heat, excessive perspiration, and increased appetite accompanied by weight loss. Complaints of abdominal cramping and frequent bowel movements are customary. Patients may also describe discomfort when wearing clothing or jewelry that is close fitting at the neckline as well as generalized muscular weakness and increased fatigue. Physical exertion may cause chest pain, shortness of breath, or both. They may have a history of heart failure or cardiac dysrhythmias. A female patient may report oligomenorrhea (scanty or infrequent menses), and both genders might experience decreased libido.

Take a drug history to determine the use of iodides (oral contraceptives, contrast media) that may cause falsely elevated serum thyroid hormone levels. Similarly, severe illness, malnutrition, or the use of aspirin, corticosteroids, and phenytoin sodium may cause a false decrease in serum thyroid hormone levels.

Physical Examination

The most common symptoms are due to hypermetabolism, such as anxiety, diaphoresis, nervousness, and palpitations. The patient may have a short attention span and fine hand tremors or shaky handwriting. Note an increased resting pulse, a widened pulse pressure, or hypertension. The skin may have a sheen of perspiration or be salmon colored.

Stand behind the patient and palpate the thyroid gland at rest and during swallowing to note the size, tenderness, and nodularity. Remember that excessive palpation of the thyroid gland can precipitate thyroid storm; therefore, palpate gently and only when necessary. You may also hear a bruit when you auscultate the thyroid gland over the lateral lobes. Exophthalmos, bulging of the eye resulting in larger amounts of visible sclera, is often quite noticeable; a fixed stare because of the presence of fluid behind the eyeball and periorbital edema are also common. In patients who have had Graves disease for several years, there may be changes in the skin, such as raised and thickened areas over the legs or feet and hyperpigmentation and itchiness. Patients often exhibit fine, thin hair and fragile nails. Patients with thyroid storm have a racing heart, high fever, profound diaphoresis, diarrhea, severe dehydration, shaking, agitation, confusion, and coma.

Psychosocial

Well before a formal diagnosis, the patient may be aware that something is seriously wrong and report increased anxiety or nervousness, insomnia, and early awakening from sleep. The anxiety is often heightened by symptoms of the disease such as angina and the sense of loss of control over one's body.

Diagnostic Highlights

Other Tests: Tests include 24-hour radioactive iodine uptake, thyroid autoantibodies, antithyroglobulin, nuclear thyroid scan, and electrocardiogram.

Collaborative

Most patients are diagnosed and treated on an outpatient basis. The goal of treatment is to return the patient to the euthyroid (normal) state and to prevent complications. Graves disease is treated pharmacologically (see Pharmacologic Highlights). Radioactive iodine (131I) is given for two purposes: for diagnosing imaging in low doses and for therapeutic destruction of the thyroid gland in larger doses. Radioactive iodine is considered the definitive and most common treatment, but it is not without risks. The principal disadvantage is the potential for hypothyroidism because 40% to 70% of patients treated with 131I develop hypothyroidism within 10 years after treatment. Other complications include parathyroid damage and exacerbation of hyperthyroidism. Surgical treatment with thyroidectomy is no longer the preferred choice of therapy for Graves disease but is an alternative therapeutic approach in some situations. In particular, it is used for patients who cannot tolerate antithyroid drugs, have significant ophthalmopathy, have large goiters, or cannot undergo radioiodine therapy.

If thyroid storm is suspected, emergency treatment needs to be instituted immediately. Patients may need cardiac monitoring, intubation and mechanical ventilation with supplemental oxygen, and IV fluids. The patient requires antithyroid medications and may receive IV corticosteroids and beta-adrenergic medications.

Pharmacologic Highlights:

Other Drugs: Beta-adrenergic blockers, corticosteroids, radioactive iodine

Independent

Nursing interventions center on ongoing monitoring, protecting the patient from injury, reducing stress, and initiating teaching. Patients with exophthalmos or other visual problems might be more comfortable wearing sunglasses or eye patches to protect the eyes from light. Report any changes in visual acuity to the physician and use artificial tears to lubricate the eyes.

Encourage the patient to follow the medication regimen and reassure him or her while waiting for it to take effect. To determine the response to treatment and to prevent thyroid storm, assess the cardiovascular status, fluid and diet intake and output, daily weights, bowel elimination, and the ability of the patient to perform activities of daily living without excessive fatigue. Reassure the patient's family that the patient's mood swings, nervousness, or anxiety will diminish as treatment continues. If the patient or family requires additional support, ask a clinical nurse specialist or mental health counselor to see the patient or family. Note that extreme anxiety of the undiagnosed or uncontrolled patient makes patient education difficult for all concerned. If you recognize the patient's inability to maintain long cognitive or physical attention spans, you will have better success at patient education. One useful strategy is to ensure that significant others are present during all teaching sessions.

Evidence Based Practice Health Policy

Langén, V., Niiranen, T., Puukka, P., Lehtonen, A., Hernesniemi, J., Sundvall, J., . . . Jula, A. (2018). Thyroid-stimulating hormone and risk of sudden cardiac death, total mortality and cardiovascular morbidity. Clinical Endocrinology, 88(1), 105–113.

• The authors proposed to investigate the association of thyroid function and TSH with total mortality, cardiovascular disease outcomes, and sudden cardiac death. They used a nationwide population-based study in Finland with 5,211 patients 30 years of age and older, and they followed the patients for a median of 13 years.
• The authors found that high TSH levels at baseline were related to a greater risk for total mortality as compared to normal TSH levels. Low TSH was not associated with higher mortality or cardiovascular disease outcomes. They suggested that more work needs to be done to study the effects of TSH on sudden cardiac death.